The Integrated Operating Room
Integrated operating rooms (I-ORs), when optimally designed, can lessen the complexity of the most complicated environment in the hospital—the surgery suite. User-friendly, integrated technologies augment surgeons' skills and help the entire surgical team work more safely and efficiently. The development and growth of minimally invasive surgery (MIS) has spurred the creation of I-ORs. Today, more than half the surgery cases in the United States are performed with minimally invasive techniques.
MIS requires only small incisions through which slender surgical steel tubes are inserted to route surgical instruments, cameras, aspiration tubes, lights, and air-management devices to the anatomy. A high-quality, magnified video, projected on a flat-screen monitor, gives the surgeon an optimal view of the surgical field (figure 1). The small incisions mean less pain, faster healing, and shorter hospital stays—or no hospital stay at all. As MIS continues to grow and robotic surgery and telemedicine become more common, I-ORs will become an industry standard, likely within the next few years.
A magnified video image, projected on a flat-screen monitor, gives the surgeon high-fidelity visualization of the surgery during a minimally invasive procedure. Photo: Karl Storz Endoscopy-America, Inc.
What Is an I-OR?
In the context of an operating room, “integration” refers to functionally connecting the OR environment. This includes patient information, audio, video, surgical lights and room lights, building automation (HVAC), and medical equipment. Users can easily route A/V sources and effectively control surgical equipment. When integrated, all technology can be manipulated from a central command console by one operator.
Compare that with the nonintegrated OR, where an assortment of equipment is arranged around the surgical table and individual pieces are pulled up or pushed back as needed. A circulating nurse works amid the equipment to change settings at the request of the surgeon—e.g., increase pressure on the insufflator, adjust the lighting, or capture an image. Cables and cords from the equipment lie in the path of the nurse, the patient gurney, and even under the feet of the anesthesiologist and the surgical team. There is a risk of tripping and disturbing the surgery, of pulling out wires, and of damaging equipment.
In an I-OR, cords and cables run inside the articulating arms of ceiling-mounted lights and booms through conduits in the ceiling. Ideally, there are no cords or cables on the floor to trip on or roll a cart over. The circulating nurse works from a console at a control station, where she has access via a computer to numerous devices in the room. No longer is she navigating the room during surgery. In fact, she is not even approaching the sterile field. All controls are on a touch screen, and the nurse can carry out the surgeon's requests from this common control station for all equipment. A surgeon may also have a command console within reach in the surgical field. Some systems even offer voice recognition and activation so that the surgeon, wearing a wireless headset with a microphone, can control the system directly.
Levels of Integration
VE level. I-ORs can be integrated at a variety of levels. At the minimal, or VE, level, video from medical equipment is fixed in the room. The video sources are images from the arthroscopic, laparoscopic, and endoscopic cameras. These video images are displayed on specific flat-panel monitors hung from the ceiling boom or on a cart near the surgeon. He views these while performing surgery. Music may be present in the room, but it is provided by equipment no more sophisticated than a boom box.
AVT level. Classic A/V and teleconferencing systems are at the AVT level of integration. These systems are used for conference room and auditorium presentations and may have music, television, and projection systems. They are typically provided by manufacturers of nonmedical devices.
AVER level. The next level of integration is the AVER level (audio, video, medical equipment, room environment), which enables easy access and control of all equipment and video switching. Video switching, or routing, allows for video images to be redirected to two or more displays. Surgeons can play music from a private playlist of MP3s or iTunes, or they can even connect their iPods to a high-fidelity A/V system with in-ceiling speakers. These audio systems, surgical video systems, and room environment controls are interlinked so that the surgeon (via a nurse at the central control unit or via voice activation) can manipulate a multitude of devices—for example, an in-surgical-light camera, a surgical instrument light source, a vacuum pump, room lights and temperature, and videoconferencing. All equipment is integrated and working together.
AVERPI level. In general, when we speak of I-ORs, we are referring to at least an AVERPI level of integration (audio, video, medical equipment, room environment, Picture Archive and Communications System (PACS), and information system). At this level, the I-OR is connected to other areas of the facility, such as radiology and laboratories. PACS images—computer desktop images with data images such as lab results—can be routed to displays within the I-OR suite and digital picture images taken earlier can be accessed and viewed on monitors. A specialized information system may collect information specific to the case and present it on a large display at the wall to organize the surgery and its functional progress. This display of case knowledge improves safety while documenting the progress and maintaining staff orientation (figure 2). When the surgeon takes a biopsy and sends it to the lab for analysis, images from the lab microscope can be sent back to the I-OR so that the surgeon and the pathologist can consult via phone while the surgery is in progress, avoiding delays that in the past would have meant a second surgery.
On the OR “wall of knowledge,” a surgery image appears on one screen (on left) via a surgical field camera; LiveData's OR-Dashboard visually integrates information from disparate sources on another large screen (at top, right); and PACS images appear on two additional screens. Photo: Richard DeWitt, Memorial Sloan-Kettering Cancer Center
AVERPIT level. The most fully integrated systems, at the AVERPIT level (figure 3), add telemedicine, which connects the I-OR to the outside world. Audio/videoconferencing extends communication abilities to conference rooms and classrooms across the street or around the world, so that surgeons can consult and teach remotely. In fact, this level extends the skill set of a specialty surgeon, thus helping to expand a scarce resource.
At the AVERPIT, or highest, level of integration, audio, video, medical equipment, room environment, PACS, information systems and telecommunications all work together in the OR. Images and data can be resourced or shared with other areas of the hospital, and tele/videoconferencing capabilities extend to the outside world. Photo: Stryker Communications
The AVERPI and AVERPIT levels of integration provide the flexibility to utilize the surgical suite for many types of cases, which is advantageous for the hospital. However, to meet the large capital outlay required for these levels of OR integration, many health systems must employ a multiyear rollout of the technology. Therefore, we recommend designing and building all ORs to be adaptable for accommodating these levels of technology integration in the future. Including the conduit, back boxes, and wall backing in rooms ready for future years' capital outlay only adds slightly to construction cost. Then, when the capital is available, installing the integration system is simple and requires minimal downtime. Otherwise, the room would have to be shut down for wall and ceiling work, creating infection-control issues and lost revenue during construction. The “adaptable” approach may be compared to the “universal” approach which requires all rooms to be constructed for all levels and be fully fitted-out with equipment.
Benefits of Integrated ORs
During the past two decades, changes in reimbursement policies and a trend toward shorter inpatient stays have made surgery, by far, the leading generator of revenue for hospitals. That's one reason hospitals are increasingly seeking to build state-of-the-art operating rooms. Attracting and retaining star surgeons by offering them the most advanced tools brings more procedures to a facility.
Another goal is improved safety. One example: Knowledge or bulletin board systems are now available that integrate patient and staff information, as well as equipment and process documentation, and post them on a wide screen in the room. A preincision screen, intraoperative screen, closing screen, and case-summary screen bring together an array of real-time data, such as the patient's vital signs, blood loss, and fluid levels. And because simple human errors, such as misidentification of a patient, can lead to life-threatening medical errors, the knowledge board displays the procedure name, patient name, gender, age, weight, and critical information such as allergies and special needs. In addition, the names of all staff in the I-OR are listed. The goal is to manage and coordinate details in order to reduce medical errors.
In the past, all this information remained on unconnected devices. The information gathering was abbreviated and many times incomplete. This design for technology integration improves quality of data capture and work flow. The surgeon looks comfortably at his or her screens as opposed to looking to the side or behind to a system-on-a-cart solution.
Repetitive suturing and other surgical tasks can cause hand, back, and leg fatigue. This requires frequent resting, extended surgery time, and varying degrees of precision. Integrated systems coupled with MIS minimize surgeon fatigue and improve patient outcomes. Many surgeons have a calming and mood-setting music playlist designed for their process. Not unusual are music selections chosen for opening, focus, and a closing celebration.
With increased control of the I-OR, the surgical team can work more efficiently and reduce operating time. Integrating various OR components into one centrally controlled system results in optimized processes. Setup and cleanup are faster and easier because equipment doesn't have to be connected and disconnected between procedures. The appropriate equipment swings into place via overhead booms, and monitors are easily positioned for optimal viewing by each surgical team. Unprecedented operating efficiency correlates with increased productivity and better utilization of every I-OR every day.
The ability to reconfigure a room by using the control console to select the case type or surgeon setup makes the rooms flexible. The intent is to enable the facility to adapt to future additions, changes, and use/practice of technology.
Planning for an Integrated OR
When a facility is being built or renovated, incorporating I-ORs has a significant impact on planning and design. Because each one of many, disparate stakeholders has a specialized interest in how the rooms are designed and how the technology will be deployed, a qualified medical technology planning firm should be brought on board at the earliest planning stage to coordinate with all these stakeholders. From the surgeons and clinicians to the IT department, radiology, biomedical engineering, architects, and contractor, many key players have concerns that must be addressed.
Waiting for planning until after construction has begun leads to back-end support systems' not being ready for the “scaled-up” network and server performance requirements. Some PACS systems are centrally located miles away from the hospital. File sizes of the images to support intervention may be extremely large—from 50 to 900 MB. Over conventional networks, it might take half an hour for a server to get these images to the I-OR. Therefore, the IT process flow for PACS and the network need early evaluation and planning.
To help the clinical/physician staff reach decisions on the technology, the technology planner should coordinate with a variety of vendors to conduct on-site equipment evaluations. Also, the planner should provide a detailed work plan and guidance on integrating radiology, cardiology, gastroenterology, orthopedics, anesthesiology, and nursing and physicians.
It is important not only to consider what is needed now but also to plan ahead for what will be needed in the foreseeable future. Creating an open-architecture system will allow equipment updates when new and better technologies come on the market, and any camera system, scope system, and PACS system can work together and will be compatible with future added components.
Designing Spaces That Support Integration
In addition to housing a large amount of technology, I-ORs impact work flow. Factors that must be considered in the design of an I-OR include total room size and best placement of lights, cameras, monitors, and the AV equipment. Furthermore, ceiling structures, articulating display arms, and equipment booms should be designed to allow for added capabilities in the future. Additional space is required for the infrastructure and electronics to support the components outside the I-OR.
In general, I-ORs are 15% larger than their nonintegrated counterparts. It is true that some equipment is smaller than ever before, but an in-room control or documentation center adds about 100 square feet to an OR. With integrated technology, a general I-OR is about 600 square feet, a cardiovascular I-OR or one that includes robotics may approach 800 square feet or more, and an I-OR with in-room imaging equipment requires at least 1,000 square feet.
The I-OR support hardware has invaded the telecommunications closet. This closet is now a 10′ × 15′ walk-in technology room that houses teleconferencing and A/V equipment, blade-server computers in racks, fiberoptic network electronics, and fiberoptic cables to the work area. This has challenged the traditional structured cable system (SCS) design, in which fiber is used to move data vertically in a building and copper is used to move data horizontally. Fiber to the desktop is a reality for the interventional I-OR. Data transport via a T1 line, an Integrated Services Digital Network (ISDN), and a Digital Subscriber Line (DSL) are common requirements for telemedicine data communications to the world.
The I-OR's video-integration technology is often housed in a 3′ × 3′ × 6′ rack. In addition, there may be three or more additional computers to support PACS, hospital information data, electronic medical records, and/or care plan documentation. There is always a question of where to place the rack, A/V electronics, and computers so they are not in the way during procedures or cleaning. One architect's innovative solution was to create a dedicated closet for the rack. The closet has a door from the corridor and a door at the inside of the room. If the video equipment needs to be updated, changed, or serviced, it can be accessed from the corridor. The inside remains closed off so the I-OR can be used for procedures not requiring integration. Servicing the technology does not shut down the room, and cleaning the OR does not disturb the equipment. The closet can be locked to secure the expensive commercial equipment.
In the surgery department outside the I-ORs, a department control desk with closed circuit TV technology and a large screen can facilitate efficiency in the suites. An image of every I-OR appears on the screen (figure 4) so that the viewer instantly knows the room status—whether or not a procedure is in progress, if the room is vacant, clean or in need of cleaning, or if it's ready for the next procedure. Providing this feature is a great aid in efficient scheduling.
Closed circuit video technology and a large screen allow the viewer to see instantly the status of every I-OR in a surgery department. Photo: Stryker Communications
Improved quality and efficiency are driving the fast-paced development of I-ORs, and the possibilities are bright for everyone concerned. Time saved through optimal technology integration means more procedures for the hospital. Surgeons and the surgical staff have the most advanced tools and an ergonomic work environment. Most important of all, patients benefit from shorter, less invasive procedures performed with the best technology and equipment available. HD